A 50 Year Old Man with Fever and Abdominal Pain

Abdominal pain can be a challenging complaint for both primary care and specialist physicians because it is frequently a benign complaint, but it can also herald a serious acute clinical condition. An epidemiologic assessment of acute abdominal pain is classified in outpatients complaining of abdominal pain on their first visit to primary care physicians including the following: whole abdominal, epigastric, right subcostal, left subcostal, right flank, left flank, periumbilical, right-lower, mid-lower, and left lower pain (1). Abdominal pain can be categorized as follows: intra-abdominal pain, abdominal wall pain, and referred pain. Patients are often subjected to a variety of procedures in an attempt to find a cause for the abdominal pain. Failure to find a visceral cause for the pain may prompt the physician to apply a functional or psychosomatic label to the patient, with any treatment directed along those lines. However, awareness that abdominal pain may have a non-visceral origin can forestall a fruitless search for intra-abdominal pathology. Abdominal wall pain is most commonly diagnosed on the basis of a patient’s history and a physical investigation. A careful history and examination, and noticing symptoms arising from abdominal wall pain, might lead to an accurate diagnosis and appropriate treatment, and it could avoid negative examinations (2-5). Carnett’s test is a clinical test in which abdominal tenderness is evaluated. It is useful for differentiating abdominal wall pain from intra-abdominal pain. While supine, the patient is asked to perform a straight-leg-raising maneuver while the examiner’s hand touches the painful site. Raising only the head while in the supine position achieves the same purpose. These maneuvers tighten the rectus abdominis muscles, increasing the pain from the entrapped nerve. True visceral sources of pain are associated with less tenderness when abdominal muscles are tense (2, 6). A previous study reported that Carnett’s test has a sensitivity of 81% and a specificity of 88%. The constant site of tenderness has the highest sensitivity (97%) but the lowest specificity (54%), whereas superficial tenderness has the highest specificity (90%) with a sensitivity of 84%. Another study, proposed criteria for diagnosing abdominal wall pain, and tested 33 patients with abdominal wall pain compared with 62 patients with intra-abdominal pain; they found a sensitivity of 85% and specificity of 97%, which appeared to be better than those for the Carnett’s test alone (9). This suggests that clinical methods are sufficient to diagnose abdominal wall pain in most cases and can be used to rule out other possible diagnoses (Table 1) (7-11). If Carnett’s test is positive, pain relief after an accurately placed nerve block or trigger point anesthesia injection can lead to diagnostic therapy. Pain relief with anesthesia injection affords excellent reassurance to the patient when effective (3, 12, 13). Carnett’s test may not be interpretable in patients who cannot adequately comply with leg or head-raising maneuvers. False positive results may occur from visceral causes of pain that involve the local parietal peritoneum (14). Psychogenic abdominal pain is inextricably linked to the origin of pain. The pain is often described as severe and persistent, having been experienced for several years and being constantly present. The pain is consistent with the anatomy of the nervous system, and no organic pathological or pathophysiological mechanism can be classified to the physical findings. Patients usually appear well compared with intra-abdominal patients (15, 16). In this issue of Internal Medicine, Takada et al evaluated the diagnostic usefulness of Carnett’s test for psychogenic abdominal pain, which was established by a retrospective study in 5,399 outpatients with abdominal pain. The differentiation of psychogenic abdominal pain from intra-abdominal pain has not yet

The Tip of the Iceberg: The Prevalence of Functional Gastrointestinal Diseases in Children

Index of Suspicion

The Narcotic Bowel Syndrome: Clinical Features, Pathophysiology, and Management

After completing this article, readers should be able to: Recurrent abdominal pain (RAP) is a frequent and troublesome complaint in childhood and adolescence, and the search for a cause and a credible approach to management can be taxing for both family and physician. The term “recurrent abdominal pain” was coined by the British pediatrician John Apley, who first published on the subject in 1958. His definition included at least three attacks of pain occurring over a period of 3 months that were severe enough to affect activities and for which no organic cause was identified. In practice, the definition may include any child or adolescent who has RAP for which the family seeks medical attention and explanation, even if the duration of the pain does not adhere strictly to the Apley definition. The definition explicitly excludes the many causes of acute abdominal pain, which lie outside the scope of this review.There is wide variation in the threshold of severity and frequency that must be crossed before a family will seek medical attention for a child who has RAP. Inevitably, parents want a clear explanation and reassurance that no sinister causes lurk undetected, and the clinician wants to oblige but often lacks the conviction that organic causes have been excluded. The most difficult challenge for the clinician is to determine to what extent diagnostic studies should be employed before the label “recurrent abdominal pain” is applied. Whereas abdominal pain may be the chief manifestation of a large number of precisely defined illnesses, more than 90% of the time a “disease” will not be defined and the family will be left with a “functional” explanation. In spite of extensive study and a vast literature base, RAP remains an elusive symptom in search of an etiology. How to diagnose and manage this common pediatric problem constitutes the subject of this review.RAP has been reported to occur in 10% to 15% of children between the ages of 4 and 16 years. A community-based study of 500 adolescents (mean age, 15.5 y) revealed that 13% to 17% experienced weekly pain, which in 20% of cases was severe enough to affect activities. There clearly is an overlap between the “normal” population that may experience recurrent pain symptoms but not complain sufficiently to seek medical attention and others who have a seemingly similar degree and frequency of pain and do come for assessment. Many sociocultural, familial, and emotional factors determine a child’s response to pain, and these also will affect the likelihood of seeking medical attention to explain and treat the problem. Although Apley and others have reported RAP to be the most common pain syndrome of childhood, headaches and limb pains appear to have an equal prevalence.In a study of 1,000 school-age children, RAP affected males and females equally up to 9 years of age. After 9 years, the incidence in females increased such that between 9 and 12 years, the female-to-male ratio was 1.5:1. The overall incidence appears to peak at 10 to 12 years. RAP is rare among children younger than 5 years of age, and an organic cause must be considered even more carefully in this younger age group. The vast literature published on this subject reveals no evidence of changes in the incidence or clinical profile of this common pediatric pain syndrome; it seems to be here to stay.The origins of abdominal pain are complex and do not lend themselves to a single model of causation. Numerous organic disorders lead to abdominal pain; in most, the pathophysiology is related to inflammation (eg, Crohn disease) or distension or obstruction of a hollow viscus (eg, obstructive uropathy). Most studies indicate that fewer than 10% of children who present with RAP have an identifiable organic etiology.The exact mechanism of pain remains unclear in the majority of children in whom no organic cause can be identified. The most typical pattern of periumbilical pain so characteristic of RAP appears to be visceral in origin, probably originating in the small intestine or colon. To date, no pattern of consistent motility disturbance has been identified in any subgroup of patients experiencing nonorganic abdominal pain. Emotions, cognitive processes, and other central nervous system influences may modulate the perception of pain to produce an altered awareness of the discomfort from these visceral sensations. This “visceral hyperalgesia” describes a heightened awareness of sensations that might not be perceived or expressed as pain in other children.Models that try to relate psychological influences in a primary causal manner (emotional stress leads to RAP) are too simplistic. However, stress can cause recognized physiologic effects, such as increased cortisol levels, sympathetic tone, and tachycardia, so it is entirely plausible that it could exert physiologic effects on the gut through altered motility or some other as yet unidentified mechanism.Oft-repeated assumptions that children who have RAP are anxious, perfectionist, socially unskilled, and self-conscious have taken on an aura of validity that is unsupported by objective evidence. Several case-control studies have failed to demonstrate significant differences for a range of measures of psychological distress between groups of children who have “functional” RAP and those who have a demonstrable organic cause for their pain. Others contradict these studies, showing that those who have RAP have higher levels of anxiety and depression than do “well” children. Illness or pain clearly causes anxiety and distress, but this must be distinguished from invoking “stress” as a source of primary causation. There are no objective methods of measuring stress, and what seems to be a source of stress for one child (eg, birth of a sibling, upcoming athletic or music competition) may be of no apparent emotional consequence for another child of the same age. As in adults, some children seem to “buckle under stress” and become anxious and emotionally distressed; others facing the same challenge become invigorated and rise to new heights of effort and achievement.For some children, anxiety and emotional stress seem to manifest in a range of pain complaints, of which abdominal pain and headache are the two most common. Parents sometimes can date the onset of the pain to a specific time, such as the beginning of a new school year or a marriage breakup. Family dynamics and individual coping styles influence the way in which children express or even acknowledge their pain. Some families encourage their children to express pain in ways that unwittingly may reinforce the complaint.The tripartite classification proposed by Barr may be the most helpful method of categorizing children who present with RAP. This classification includes: 1) those who have organic disease, 2) those who have a clear psychogenic etiology such as depression or school phobia, and 3) the traditional “functional” group in which neither organic disease nor a clear psychogenic etiology is manifest.The majority of children who have RAP are considered to have a functional etiology. The problem of defining functional RAP is daunting. In its simplest form, the concept encompasses all causes that do not have an identifiable organic etiology. Most typically, the pain occurs in episodes that are periumbilical, self-limited, unrelated to meals or activities, and rarely if ever sufficient to awaken the child from sleep. The growth pattern and findings on the physical examination are normal. The degree of interference with normal activities and school attendance may seem out of proportion to the frequency and severity of the episodes as described. It has been observed wryly that “Organicity of pain is inversely proportional to the number of school absences.”Some children who have RAP manifest many of the characteristics associated with irritable bowel syndrome (IBS), as defined in adults. The criteria for making this diagnosis are: 1) abdominal pain relieved by defecation, 2) more frequent stools at the onset of the pain, 3) altered stool form (hard or loose or watery), 4) passage of mucus, and 5) associated bloating or abdominal distension. To define this syndrome requires a degree of detail regarding bowel function that the clinician will find difficult to elicit from children, who are notoriously reluctant to reveal or discuss their bowel habits. In adults, the division is made between those who have constipation-dominant and diarrhea-dominant symptoms. There is some evidence that altered intestinal motility, mediated by peptides excreted by both gut and brain, plays a role in the etiology of IBS. There are no laboratory markers; the diagnosis rests on the history. Although some clinicians include constipation under the diagnostic category of IBS, most recognize it as a separate diagnosis.Many factors lead to constipation in children, the foremost of which is dietary. Modern diets are replete with highly processed starches, and many children shun fruits, vegetables, and higher-fiber foods. An unwillingness by some children to take the time to evacuate their bowels completely, coupled in some cases with a reluctance to use school washrooms, can seriously compound this problem. Sometimes the role of constipation as a major contributing factor to abdominal pain will be clear, with the parent noting that the child goes days between bowel movements and that the stool is bulky and hard. Often the pediatrician faces the problem of ferreting out this diagnosis in the face of inadequate history; the parent is unaware of the child’s bowel pattern and the child is tight-lipped and unwilling to discuss the matter in any detail. Findings on abdominal and rectal examinations may not confirm this diagnostic suspicion; a plain abdominal radiograph may be needed.There may be a long latency between onset of symptoms and a confirmed diagnosis of inflammatory bowel disease (IBD). Although ulcerative colitis often presents with abdominal pain associated with hematochezia and tenesmus, the early symptoms of Crohn disease may be more insidious and nonspecific. Abdominal pain and diarrhea may be intermittent, and the clinician must be alert to the presence of lethargy, growth and pubertal delay, and extraintestinal manifestations such as oral, joint, and perirectal involvement. With the widespread availability of endoscopy, a diagnosis usually can be made promptly.The frequency with which incomplete absorption of lactose and other carbohydrates produces RAP in children is unclear, as are outcomes in several large and well-conducted studies. Initial enthusiasm for this diagnosis as a significant cause for RAP has waned. A wide range of racial/ethnic groups—Asian, Jewish, Mediterranean, and African-Americans—are predisposed to lactase deficiency, with incidences reported as high as 60% to 80%. Lactose ingestion will cause symptoms of bloating, loose stools, and cramping abdominal pain in those who are affected. It appears to be an uncommon cause of RAP in the absence of other gastrointestinal symptoms. The diagnosis is made most reliably by breath hydrogen testing. If this diagnostic tool is unavailable, it is reasonable to use lactase-treated milk products or a complete restriction of milk products for several weeks as a therapeutic trial. It is important to recognize that lactose intolerance results simply in carbohydrate maldigestion; it is not, per se, a cause of malnutrition or growth failure.The discovery of H pylori has changed the approach to diagnosis and treatment of peptic ulcer disease. Epidemiologic evidence indicates that this infection is more prevalent among those living in low socioeconomic circumstances, so infection rates are significantly higher in less developed nations. Even in developed countries, the prevalence of H pylori infection is approximately 40%. However, the great majority of affected individuals have no signs or symptoms; they have infection but no disease.The intense interest in H pylori has generated numerous tests and treatments that, unfortunately, are being used in excess of their established benefits and often counter to the best interests of the patient.Several lines of evidence indicate that H pylori infection alone rarely is the cause of abdominal pain in children unless peptic ulcer disease is present. A meta-analysis of more than 40 published reports shows strong evidence for an association between H pylori gastritis and duodenal ulcer disease in children, but weak or no evidence for an association between H pylori infection and RAP. Serologic studies have shown that antibodies to H pylori occur with similar prevalence among children who do and do not have RAP. In a large multicenter study from Germany, symptom assessment could not distinguish between children who had H pylori gastritis and those who had “functional” RAP. Symptoms improved or resolved in 87% of children in whom H pylori was eradicated successfully, but also in 93% of those in whom eradication failed and in 80% of those who had “functional” RAP. H pylori-associated peptic ulcer disease should be suspected when abdominal pain is primarily epigastric; when it awakens the child from sleep; and when it is associated with anorexia, nausea, recurrent vomiting, anemia, or gastrointestinal bleeding. Although abdominal pain is common in children, peptic ulcer disease is very uncommon; therefore, testing for H pylori should not be part of the preliminary evaluation of a child who has RAP.Given the important distinction between H pylori infection and disease, engaging in a fishing expedition for evidence of H pylori infection is not an appropriate strategy for investigating RAP. Antibodies in serum or saliva may remain elevated for years after infection has resolved, making their mere presence unhelpful in initial diagnosis. The urea breath test is reliable for detecting the presence of H pylori infection, but many causes of esophagitis, gastritis, and peptic ulcer disease present with similar symptoms. Therefore, when the weight of symptoms suggests the presence of ulcer disease, endoscopy with biopsies is the optimal approach for confirming the diagnosis and guiding treatment. Fecal antigen tests look promising, but their role in children has not yet been defined.H pylori causes approximately 70% of primary peptic ulcer disease in children, but about 30% is idiopathic. In addition, secondary ulcer disease may be associated with nonsteroidal anti-inflammatory drug ingestion, Crohn gastritis, and other forms of erosive gastritis.Dyspepsia is a symptom complex of epigastric pain, bloating, and discomfort that may occur with or without demonstrable acid reflux. “Nonulcer dyspepsia” is designated when these symptoms are accompanied by negative endocopic and biopsy findings.The association between migraine and abdominal pain remains mysterious, and many clinicians view the existence of a discreet entity of “abdominal migraine” as dubious. Because migraine is a common problem in both pediatric and adult medicine, with a prevalence reported to be as high as 5%, some children who have headache due to migraine also will experience RAP. “Abdominal migraine” usually is recognized when episodes of paroxysmal abdominal pain occur in association with nausea and vomiting, with complete recovery between episodes and sometimes with associated headache. A strong family history of migraine lends credibility to the diagnosis. Most pediatricians only accept abdominal migraine as an explanation for RAP when the patient has headaches that are conclusively migraine.The contribution of parasitic infestation to RAP is elusive. Infection with Yersinia enterocolitica can cause enteritis that mimics IBD, albeit usually associated with diarrhea. It is well-recognized that infestation with Giardia can cause diarrhea associated with abdominal cramps and pain, but diarrhea usually is the predominant complaint. The possible role of Dientamoeba fragilis and Blastocystis hominis in causing RAP in the absence of diarrhea has been raised in a small number of studies, but their role remains dubious. With the present state of knowledge, a search for an infectious etiology for RAP is not usually warranted in the absence of diarrhea.Many gynecologic conditions can present with RAP and must be given careful consideration, especially in postpubertal females. Early menarche, endometriosis, pelvic inflammatory disease, and ovarian cyst are important diagnostic possibilities. Many of these causes can be elucidated by ultrasonographic examination.Abuse always requires careful consideration in children who have RAP, and sensitive history taking is required to elucidate its possible role.It is heartening to reassure clinicians in the 21st century that the most powerful diagnostic tools they bring to the problem of RAP in childhood are a thorough history and physical examination. The proliferation of diagnostic technology threatens to obscure the foremost need that patients and their families be heard, not investigated. A correct diagnosis usually can be suspected following a good history and physical examination. In addition to their diagnostic roles, a complete history and physical examination will help to convince parents that their concerns are taken seriously.A successful history places the patient and family at ease and allows them to express their concerns unhurriedly. As children advance in age, they are included in the history taking, and part of the interview of an adolescent should take place separately from the parents. It may be wise to conduct the initial interview with the parents alone; this should be discussed with the parents at the outset to reach a mutually agreeable decision. Successful interviewing involves active, empathetic listening followed by explanations given in language and terms that the family understands. The most satisfied parents are those who feel that they have been heard, and the physician who listens well earns a high degree of confidence and credibility.The history should explore the location, nature, and frequency of the pain, along with associated symptoms. It should be acknowledged that the child’s description of the nature of the pain (eg, sharp, dull) is of limited importance in making a diagnosis because children often are unclear as to the meaning of these descriptors. The relationship of the pain to school and social/family stressors is important to elicit. 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In most should be limited to a complete and examination of a stool for In the presence of significant a stool for and and examination is role of is important but limited and requires careful A single view of the can be in defining the presence of significant especially when is high but the history is and results of the physical examination are of abdominal as a tool seems very limited on However, it can be for causes of abdominal pain, when the is (eg, obstructive or gynecologic (eg, ovarian or the gastrointestinal causes such as an also may be revealed by It is an appropriate when the pain is when are on or when the pain to the in a of any is considered as a possible serum and levels, and stool for should be this diagnosis is highly for and is gastrointestinal and small bowel remains a in the diagnosis of Crohn disease. is levels have been as a sensitive test for IBD, but their role as a clinical tool remains to be the pattern of pain suggests peptic ulcer disease, gastrointestinal endoscopy with biopsies is the optimal approach to diagnosis. or acid peptic disease is given diagnostic consideration, to a to in diagnosis and management is the complex nature of abdominal pain in children, the clinician to have sufficient and experience to when to and when to many cases of RAP may reveal a diagnosis on first diagnostic in others may be only after several and the of The clinician should an approach that allows of a diagnostic before making management may appropriate the majority of the diagnostic will be one of functional RAP. The first and most is to explain the concept of functional abdominal pain to the parents. Many parents will that pain that has a or the child is The most method of the parents of this is to the abdominal pain with headache in adults. 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In a of patients who had RAP from the and the complaint 5 to years after their initial A study by and that more than one of RAP patients had or recurrent abdominal symptoms as adults, and one of especially well-conducted studies of RAP patients by and patients 5 to years after initial who had RAP reported significantly higher levels of abdominal pain and other as many from or and made significantly more the years than the well the best the pediatrician can demonstrate is that the pain will be that for some this will not be the who has with RAP is left with some anxiety that a significant organic diagnosis has been that will appear at some time to an at the clinician who in that the cause was This seems to be a rare and evidence of organic disease in only 3 of and other studies have shown similar low abdominal pain in childhood will to to diagnosis or treatment. The wise clinician will a careful evaluation first and foremost on a thorough history and physical as appropriate by

In Reply: Chronic and Complex Myofascial Pain Syndromes in Chronic Abdominal Wall Pain

Research indicates a deleterious effect of sleep disturbances on pain and illness-related functioning across pediatric populations. Sleep problems in youth with functional gastrointestinal disorders (FGIDs) are understudied, despite studies in adult FGIDs indicating sleep disruptions increase pain and symptom severity. This study sought to better characterize sleep problems in school-age children with FGIDs and to assess relationships with demographic characteristics and gastrointestinal symptoms. Sixty-seven children with FGIDs (pediatric Rome IV criteria) and 59 parents completed questionnaires assessing sleep problems, and children completed a 2-week pain/stooling diary. Sleep problems in this sample were compared with published normative samples, and children above and below the clinical cutoff were compared on demographics and FGID symptoms. Of the sample, 61% were above the clinical cutoff for sleep disturbances, with significantly greater bedtime resistance, sleep onset delay, sleep duration, and daytime sleepiness than the comparison group. Children above the clinical cutoff reported greater mean abdominal pain severity and pain interference. Relative to White participants, Black/African-American participants were more likely to be above the clinical cutoff and indicated more frequent night wakening and symptoms of sleep-disordered breathing, but lower maximum and overall mean abdominal pain severity. Sleep problems in children with FGIDs are common and related to greater day-to-day abdominal pain severity and pain interference. Results suggest sleep-pain relationships may differ across racial/ethnic groups. Assessing sleep in children with FGIDs is important, and further research is needed to assess underlying mechanisms and evaluate sleep as a potential treatment target in this population.

Redux: Do Little Bellyachers Grow up to Become Big Bellyachers?

Ectopic pregnancy is a terminology which is utilized for the scenario in which a fertilized eggs has implanted outside the uterus [5] which usually has tended to be within one of the fallopian tubes. The classical manifestations of ectopic pregnancy do include abdominal pain and bleeding per vaginam; nevertheless, it has been stated that less than 50% of women who are afflicted by ectopic pregnancy are stated to have both symptoms of abdominal pain and vaginal bleeding. The lady who has ectopic pregnancy could describe the abdominal pain as sharp pain dull pain, or crampy pain. The abdominal pain could also extend to affect the ipsilateral shoulder due to irritation of the diaphragm in the scenario of of bleeding from the ectopic pregnancy into the abdomen. Severe bleeding into the abdomen from ectopic pregnancy site into the abdomen or through the vagina could emanate in the patient developing a fast heart rate (tachycardia, fainting, or shock and on rare occasions the foetus may not have the chance to survive [6] When the patient who has ectopic pregnancy manifests with abdominal pain and bleeding from the vagina, the patient tends to be seen by a gynaecologist but when the patient presents with abdominal pain, loin pain or shoulder tip pain, the patient could in the first instance be seen by a General Practitioner, a general surgeon, a physician or a Urologist on rare occasions and hence even though ectopic pregnancy is a gynaecological practitioner, every clinician including General Duty Practitioners and Emergency clinicians need to have a high index of suspicion for ectopic pregnancy in order to establish a quick and accurate diagnosis to enable prompt and appropriate treatment of the patient. Some of the risk factors for the development of ectopic pregnancy do include: pelvic inflammatory disease, smoking of tobacco, previous tubal surgery, a history of infertility, utilization of assisted reproductive technology. In most hospitals globally, diagnosis of ectopic pregnancy tends to be established via utilization of blood tests for human chorionic gonadotrophin and the undertaking of ultrasound scan of abdomen and pelvis to demonstrate presence of the ectopic pregnancy. Nevertheless, in some small hospitals where facilities for ultrasound scan are not immediately available as well as in scenarios where serum beta human chorionic gonadotrophin are not immediately available on such rare occasions based upon a high index of suspicion for ectopic pregnancy the emergency general duty practitioner tends to subject the patient to surgical operation and during the procedure the ectopic pregnancy would be diagnosed and dealt with accordingly. Some of the differential diagnoses of ectopic pregnancy include: miscarriage, torsion of the ovary, appendicitis if the ectopic pregnancy is on the right side, rupture of corpus luteum cyst. Some of the treatment options that have been utilized for ectopic pregnancy include: surgery with various forms of surgical operation including salpingectomy, as well as achieving abortion via treatment with methotrexate. With regard to mortality associated with ectopic pregnancy the mortality has tended to 0.2%, but the mortality associated with ectopic pregnancy within the developing world has been 2%. Ectopic pregnancy is stated to account for 1.5% of pregnancies within the developed world. Conclusion Ectopic pregnancy is a condition that tends to manifest with bleeding from the vagina plus abdominal pain but it could also manifest as abdominal pain alone and hence a patient with ectopic pregnancy may initially present to an emergency clinician, an obstetrician, / gynaecologists, a General Practitioner, a General Surgeon and on very rare occasions to a Urologist. A high index of suspicion is required to diagnose ectopic pregnancy based upon determination of serum Beta Human Chorionic Gonadotrophin levels as well as undertaking of ultrasound scan of abdomen and pelvis in order to provide appropriate and effective treatment based upon the clinical state of the patients as well as whether or not the patient has a desire to be pregnant again in the future. It is important to appreciate that a patient who has ectopic pregnancy could be seen for the first time by various clinicians including gynaecologists, emergency clinicians, general surgeons and even urologists. A lady who has pain in the right lower quadrant of the abdomen could be considered to have differential diagnoses, some of which include appendicitis, and ureteric colic and hence it is important to consider ectopic pregnancy as a possible diagnosis in cases of right sided lower abdominal and suprapubic pain Considering that occasionally a patient who has ectopic pregnancy may first be seen by non-gynaecologists, it is important for all clinicians to have a high index of suspicion to exclude ectopic pregnancy when they see ladies in their reproductive ages who manifest with vaginal bleeding and abdominal pain or abdominal pain alone.

Efficacy of Treating Abdominal Wall Pain by Local Injection

Chronic abdominal wall pain is a poorly recognized cause of chronic abdominal pain, and patients frequently go misdiagnosed despite a battery of medical tests. The Carnett's test is a diagnostic tool used to distinguish between abdominal wall pain and visceral pain. This review synthesizes the current literature on the Carnett's test, merges the viewpoints of diverse writers, and evaluates and reports on the Carnett's test's applicability. Several clinical investigations have established the usefulness of the Carnett's test in the diagnosis of chronic abdominal wall pain. Furthermore, the Carnett's test is quite useful in determining the depth of the mass and detecting psychogenic abdominal pain. However, its diagnostic use for acute abdominal pain is limited. The Carnett's test is a simple and safe point-of-care diagnostic technique, with several studies supporting its usefulness. Early detection of abdominal wall pain is critical for chronic abdominal wall pain therapy. Carnett's test is very useful in patients with chronic, unexplained local abdominal discomfort who are compliant and do not have a clear rationale for surgery.

BACKGROUND: Many patients suffer from abdominal and thoracic pain syndromes secondary to numerous underlying etiologies. Chronic abdominal and thoracic pain can be difficult to treat and often refractory to conservative management. In this systematic literature review, we evaluate the current literature to assess radiofrequency ablation’s (RFA) efficacy for treating these debilitating chronic pain conditions in the thoracic and abdominal regions. OBJECTIVES: The objective of this study is to determine the pain relief efficacy of RFA on chronic thoracic and chronic abdominal disease states. STUDY DESIGN: This study is a systematic literature review that uses the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method to gather academic literature articles through a methodical approach. The numbers obtained from each academic manuscript were then used to calculate the percent efficacy of radiofrequency ablation on thoracic and abdominal pain relief. METHODS: Articles from 1992 through 2022 were gathered using PRISMA guidelines. The search terms “Radiofrequency Ablation Thoracic Pain” and “Radiofrequency Ablation Abdominal Pain” were used to identify articles to include in our study. Our search yielded a total of 575 studies, 32 of which were included in our study. The articles were then categorized into pain causes. The efficacy of RFA for each qualitative study was then quantified. Risk of bias was also assessed for articles using the Cochran Risk of Bias tool, as well as a tool made by the National Institutes of Health. RESULTS: The PRISMA search yielded a total of 32 articles used for our study, including 16 observational studies, one cohort study, 6 case reports, 6 case series, and 3 clinical trials. Twenty-five articles were labeled good quality and one article was labeled fair quality according to the risk of bias assessment tools. The studies examined RFA efficacy on chronic abdominal and chronic pain syndromes such as spinal lesions, postsurgical thoracic pain, abdominal cancers, and pancreatitis. Among these etiologies, RFA demonstrated notable efficacy in alleviating pain among patients with spinal osteoid osteomas or osteoblastomas, lung cancer, and pancreatic cancer. The modes of RFA used varied among the studies; they included monopolar RFA, bipolar RFA, pulsed RFA, and RFA at different temperatures. The average efficacy rate was 84% ranging from 55.8% - 100%. A total of 329 males and 291 females were included with ages ranging 4 to 90 years old. LIMITATIONS: Limitations of this review include the RFA not being performed at the same nerve level to address the same pathology and the RFA not being performed for the same duration of time. Furthermore, the efficacy of RFA was evaluated via large case series and single cohort observational studies rather than control group observational studies and clinical trial studies. CONCLUSION: A systematic review of the literature supports RFA as a viable option for managing abdominal and thoracic pain. Future randomized controlled trials are needed to investigate the efficacy of the various RFA modalities to ensure RFA is the source of pain relief as a large body of the current literature focuses only on observational studies. KEY WORDS: Chronic pain management, radiofrequency ablation, chronic abdominal pain, chronic thoracic pain, pain measurement

Chapter 16 - Abdominal pain in gastroparesis

To evaluate the accuracy of a preliminary diagnosis based solely on patient history and physical examination in medical outpatients with abdominal or chest pain. Prospective observational study. General medical outpatient clinic in a university teaching hospital. One hundred ninety new, consecutive patients with a mean age of 44 years (SD = 14 years, range 30-58 years) with a main complaint of abdominal or chest pain. The preliminary diagnosis, established on the basis of patient history and physical examination, was compared with a final diagnosis, obtained after workup at completion of the chart. A nonorganic cause was established in 66 (59%) of 112 patients with abdominal pain and in 65 (83%) of 78 with chest pain. The preliminary diagnosis of "nonorganic" versus "organic" causes was correct in 79% of patients with abdominal pain and in 88% of patients with chest pain. An "undoubted" preliminary diagnosis predicted a correct assessment in all patients with abdominal pain and in all but one patient with chest pain. Overall, only 4 patients (3%) were initially incorrectly diagnosed as having a nonorganic cause of pain rather than an organic cause. In addition, final nonorganic diagnosis (n = 131) was compared with long-term follow-up by obtaining information from patients and, if necessary, from treating physicians. Follow-up information, obtained for 71% of these patients after a mean of 29 months (range 18-56 months) identified three other patients that had been misdiagnosed as having abdominal pain of nonorganic causes. Compared with follow-up, the diagnostic accuracy for nonorganic abdominal and chest pain at chart completion was 93% and 98%, respectively. A preliminary diagnosis of nonorganic versus organic abdominal or chest pain based on patient history and physical examination proved remarkably reliable. Accuracy was almost complete in patients with an "undoubted" preliminary diagnosis, suggesting that watchful waiting can be recommended in such cases.

The Natural History and Treatment Outcomes of Symptomatic Ovarian Vein Thrombosis.